Q&A Time: Suggestions for Highly Reactive Thoracic Pain Patients

A regular blog reader asked the following question, "Dr. E - Do you have any suggested practice patterns for thoracic pain? I often encounter patients with thoracic pain/strain who can tolerated extension and even flexion, but rotation causes a lot of pain. They cannot seem to tolerate t/s HVLAT, let alone lighter PAs. I've played around with repeated t/s EIP, but it does not seem to improve rotation. I've been worried to try thoracic whips with these patients?"

Great question Sam, in my blog, I often talk about how the thoracic spine is dysfunctional but not normally painful. For this reason, many clinicians forget to take a look for loss of rotation to the painful side that seems to correlate with unilateral shoulder, cervical, HA, radiculopathy, or other unilateral UQ issues.
For ease, let's assume that your reactive and sensitive thoracic patient only has thoracic pain. The beauty of screening for regional interdependence is you often find asymmetries that you can treat in adjacent areas that may reset the proximal painful area.
The Eclectic Approach Clinical Practice Patterns for Upper Quarter StateUnilateral Upper Quarter Symptoms

look for loss of cervical retraction and SB to the involved side

loss of passive shoulder IR and passive shoulder extension on the ipsilateral side

loss of thoracic rotation to the involved side

Bilateral/Central Upper Quarter Symptoms

loss of cervical retraction and extension

shoulders/thoracic spine either full or limited, but are symmetrical

"Thoracic Pain" is often referred from the cervical spine. Or if you're thinking purely as an output, just think of it as being often modulated by cervical repeated loading strategies. It can radiate to around the inferior angle of the scapula. If you have tried various thoracic inputs like light IASTM, mobs, P/A, and they seem too sensitized by rotation to even think about thoracic whips, try

repeated cervical retraction and extension if there is a loss and/or painful block for bilateral/central complaints

cervical retraction and SB to the involved side if unilateral

if bilateral but worse on one side and has a loss of cervical retraction and SB to the side that is worse, then try cervical retraction and SB to the side with greater loss

if thoracic symptoms are unilateral but there is no deviation in cervical extension and retraction and SB are equal, then try cervical retraction with extension

These are not laws, but rules, and you'll see them as patterns more often than not. Sam, let me know if this helps, and hopefully it helps others out there who read this.

Interested in live cases where I apply this approach and integrate it with manual therapy and repeated motions? Check it out on The OMPT Channel! Updated today with a 18 min Breathing Education Session for a Physio with Chronic UQ Symptoms.

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